The Brussels Post, 1966-05-12, Page 4PARTIALLY ASSISTED PREMIUMS
Cost for those eligible for
premium assistance
Complete Government YOu
Cost Pays Pay
(a) The single person 60.90
(covering only the member)
with a taxable income in 1965
of $500 or less
$30.00 $30.00
157.50
revery
3 months)
(c) The family of three or more $150.00 $90.00 $60.00.
(covering the head of the family (1115.03
and all eligible dependants) 31roz,„) with a total taxable income in 1965
of $1,300 or less
FULL PREMIUMS
Cost for those not eligible for premium assistance COST
(a) The single person $110.00 a year
($15.00 every 3 months)
$120,00 a year
(530.00 every 3 months)
(C) The family of three or more $150.00 a year
(covering the head of the family ($37.50 every 3 months)
and all eligible dependants)
(covering only the member)
(b) The family of two
(covering the head of the family
and one eligible dependant)
(b) The family of two $120.00 $60.00 ($ °ea y5.13°
3 months)
(covering the head of the family
and-one eligible dependant)
with a total taxable income in 1965
of $1,000 or less
",P4 VI MAY lid', 19$1 THE IPOIrli; Bit tY1381144 .ONTIi1110
.7.7.1.0.,71/771.11•,..17.•••••••
Many.quolify:for full or
partial assistance
•11.6•
ipatag
Legislation approving the Ontario Medical Services Insurance Plan-OMSIP for
short-was passed in the Ontario Le islature on Feb, 18th of this year. Coverage
commenced April 1st for social assistance recipients, Coverage will begin July 1st
for those who have already enrolled, or who enroll now before May 16th,
FOR ADDITIONAL CHILDREN ATTACH A SEPARATE SHEET
OR HEALTH
01\ISIP has been estab-
lished to provide adequate
insurance coverage for the
payment of doctors' bills,
and to make this coverage
available to all Ontario resi-
dents regardless of their age,
income or state of health.
Enrollment in OMSIP is
voluntary.
The Plan is intended for
individuals and their fam
ilies and does not provide
group coverage. (Group cov-
erage is where a number of
individuals collectively pur-
chase insurance through
their place of employment,
union, etc.)
Everyone who. has lived.
in Ontario for the past 3
months is eligible to join,,
except those who are enti-
tled to physicians' services
under another Act.
Members are free to
choose their own doctor. If
a member travels outside
the Province, and requires
care., OMSIP will still pay
the • doctors' bills up to
OMSIP established rates.
People who find they can-
not continue to may for all
or part of their OIVISIP. con-
tract because of unernploy-
inent, illness or disability,
may apply for temporary •
assistance in paying their
fees, ..
Since the aim of OMSIP leg-
islation is to provide adequate
medical insurance for Ontario
residents, full or partial pre-
mium assistance is available •
for those who require it.
Automatic fully-paid,
coverage
Many residents and their
dependants have automatic-
ally received fully paid cover-
age under OMSIP. These are
people who are already re-
ceiving,benefits under the fol-
lowing Acts:
• The Blind Persons'
Allowances Act
Yes, if you are a single person
and. your taxable income in
1965 was $500 or less.
Complete cost $60.00
Government pays. . 30.00
You. pay 30.00
($7.50 every 3 months)
• The Disabled Persons'
Allowances Act
The General Welfare
Assistance Act
• The. Mothers' Allowances
Act
• The Old, Age Assistance Act,
• The Rehabilitation
Services Act
Automatic fully-paid cover-
age is also provided for old
age security pensioners and
their dependants declared eli-
gible for coverage by the
Ontario Department of Public
Welfare.
Yes, if you have one depen-
dant, and if together your
total taxable income in 1965
was $1,000 or less.
Complete cost $120.00
Government pays . 60.00
Fully-paid coverage on
application
People resident in Ontario for
the past 12 months and who
had no taxable income in 1965
get full assistance.
This means if these people
make out their application
form now, before May 16th,
they will get OMSIP protec-
tion, fully paid for by the
governmont, starting this
July 1st.
In addition, many who have
been resident in Ontario for
the past 12 months will be
eligible for partial assistance,
depending on their taxable
income and number of de-
pendants. (See below).
Yes, if you have a family of
3 or more, and if your family's
total taxable income in 1965
was $1,300 or less.
Complete cost $150.00
Government pays 90.00
You pay 60.00
($15.00 every 3 months)
^^.^.
OMSIP PROVIDES COVERAGE
REGARDLESS OF AGE, INCOME
;<•
INSTRUCTIONS
1. If you have a Social Insurance Number write it in the
squares provided starting with the first number in
the first square. If you do not have a number, place
a v mark in the square marked NO.
2. Print your last or Family Name in the box. (Example:
Smith, Jones, Brown, etc.).
3. Print your first and second Given Names in the boxes.
(Example: John, Harry, Mary, etc.). If you have a
nickname or are commonly known by another name
for mailing purposes, please indicate in the box
marked OTHER.
4. Print your address in the first box; your City, Town,
Village or Post Office in the next box; and your
County or DiStrict in the last box.
5. Write the number of the day on which you were born
in the box marked DAY. Print the name of the month
(or its abbreviation) in the box marked MONTH.
Write the number of the year in the box marked
YEAR (Example:9 Feb, 1927).
6. Men should place a V mark in the box marked MALE,
Women should place a -V mark in the box marked
FEMALE.
7. If you are single place a V mark in the box marked
SINGLE. If you are married place a mark in the box
marked MARRIED. If your status is other than single
or married (Example: separated, divorced or widow•
ed) write your status on the line marked OTHER.
8. Write your occupation and the kind of business or
industry in which you work (Example: Carpenter-
Building Trade; Farmer-Agriculture; Salesman-
Bakery).
ADDITIONAL DEPENDANTS Birth Date
Day Month Year
9. Print the first names of your wife or husband (spouse) in the first box.
Then print the first names of all your eligible dependant children,
starting with the oldest, in the following boxes. If you have more than
five eligible dependant children continue your list in the section on this
ride of the form. If you have more than 10 eligible dependant children,
list them separately and return with your application form,
Under BIRTH DATE, write the number of the day of birth, print the
month and write the number of the year of birth. (Example: 18 Sept.1954),
Under SEX, write M if the child is male, F if the child is female.
10. Sign your name on the line marked. SIGNATURE OF APPLICANT and
write in the date and year.
11. IF YOU ARE APPLYING FOR PREMIUM ASSISTANCE
Read this section very carefully and complete either the section marked
'A' or the one marked '8' (not both).
12. Remember, if you receive benefits under any of the Acts listed under '
WTI ri the folder entitled "OMSIP...WHAT 11 MEANS AND WHAT IT CAN DO FOR YOU",
you should not complete an application, form. You will, be provided
automatically with fully paid coverage.
Sex
M or F
DO YOU QUALIFY FOR PARTIAL ASSISTANCE?
You pay 60.00
($15.00 every 3 months)
What is taxable income?
Taxable income is the amount of your income upon which you pay tax after
exemptions for dependants and other allowances have been deducted.
H ERE'S YOUR APPLICATION FORM Please use BALL POINT PEN. Cut out form carefully. Mail toda
SEND YOUR COMPLETED APPLICATION FORM TO:
OMSIP, P.O. Box 1700, Terminal A, Toronto, Ontario.
ONTARIO MEDICAL SERVICES INSURANCE PLAN
APPLICATION FORM PLEASE READ INSTRUCTIONS ABOVE
BEFORE COMPLETING
1. Do you have a I Scicial Insurande
III 1
NUmber
/1
For office use only
Social Insurance [ If yes, insert
Number?
No 0
2. Your Name
Please print
Last or Family Name - 3. Given Names (First) (Second) Other
4. Your Address
Please print
RR # or P.O. Box or Street & Number City or Town or Village or Post Office County' or Distritt
' 5. Birth Date
Day I Month Year
6. Sex
0 0
Male Female
7, Marital Status
0 0
8, OccUpatIon & Nature Of Business or Industry
Single Married , Other (specify)
9. LIST DEPENDANTS Spouse and/or Ch Idren (children must be under 21 and unmarried), Other dependants and fully employed children must apply for neperere coverage.
Given Names Only
Day
Birth Date
Month Year
Sex
M or F
Given Names Only
bay
Birth Date
Month Year
Sex
M or F
'Spouse ' 3rd child
1st child
(oldest eligible)
4th child
2nd child 5th child
10. In Applying for coverage under The Ontario Medical Services Insurance List additional dependant children in space provided above.
Act 1965, I confirm that I have lived in Ontario for he past 90 days,
I am not covered for total medical care by government andlhat the
information given by ine is correct.
Date 1
For offiCe use only
signature of Applicant
APPLICATION FOR
PREMIUM ASSISTANCE
it I have lived in Ontario for the past 12 months. I am
not covered for total medical care by government.
I agree to allow the Medical Services Insurance
Division to verify all statements made by me on
this application,
(SIGN A OR B ONLY)
A. NO TAXABLE INCOME
I hereby apply for full premium assistance
I and my eligible dependants had no taxable in.
come for the 12 manths ended December 31st last.
I state that the information given by me is correct.
Signature of Applicant
Date 19
B. TAXABLE INCOME OF $1,300,00 OR LESS
I hereby apply for partial premium assistance
My taxable income and the taxable income of my
eligible dependants was in total S for the 12 months ended December 31st last.
I state that the information given by me is correct,
Signature of Applicant
Date 19
•